An Unusual Case of Pericarditis
A 63-year-old man presented with complaints of worsening dyspnea, generalized weakness and fatigue for six weeks. He also had a one-year history of frequent upper respiratory tract infections, recurrent otitis media and bilateral hearing loss not responding to antibiotics and steroids. The patient denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, palpitations or dizziness. On physical examination, his blood pressure was 127/71 mmHg, temperature was 98.7F, respiratory rate was 20 breaths per minute, with an oxygen saturation of 97% and his heart rate was 112 beats per minute. Jugular venous distention was noted at 7 cm H2O. Cardiac exam revealed normal heart sounds, with no murmurs or pericardial rub. Lung exam was clear on auscultation. Electrocardiogram (EKG) revealed sinus tachycardia. Transthoracic echocardiography (Fig A) and subsequent cardiac MRI were performed (Fig B). A complete blood count was unremarkable, with no eosinophilia. B-type Natriuretic Peptide (BNP) was 167. Westergren sedimentation rate (WSR) and C-reactive protein (CRP) levels were elevated at 71 mm/hour and 157 mg/dl respectively. Myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA) was positive at 44 units.
Figures A & B
Which of the following is the most likely diagnosis in this patient?